Download "Emergency Room Denial Appeal Letter" Word Document
Appeal Letter Displayed for Your Convenience
Health Symphony Appeal Letter
For Emergency Room Denial
Your name and address
Address of Claims review department
RE: Name of Insured:
Plan ID #:
Dear Claims Review Department:
I am writing to you in regards to a claim submitted by [Medical Provider] for [patient]. The charges were rendered on [Date] and totaled [Claim dollar total]. [Health Plan] has denied payment stating that the Emergency Admission was not covered.
[Patient] was treated in the emergency room of [Facility/Hospital Name] on [Date of Service] as a result of [list condition(s)]. This required for the [Patient] to be taken to the nearest emergency room facility for treatment.
Option 1: There was not an opportunity for [Facility/Hospital Name] or the patient to obtain prior authorization from the health plan prior to receiving emergency treatment. Once [Patient] was stabilized on [Date] we did speak with a health plan representative to request an authorization on the emergency room treatment. We have since been told that the [Patient] had to be seen at a designated hospital, but due to the emergency situation we had to choose the nearest emergency room facility.
Option 2: We did speak with a health plan representative to request an authorization on the emergency room treatment, but the health plan indicated that pre-certification of the emergency room visit was not required and therefore one was not obtained. Consequently, we should not be penalized from receiving inaccurate information from the health plan.
Option 3: [Facility/Hospital Name] or [Primary Care Physician Name] is contracted with my health plan and as they are participating providers they should be aware that an authorization for my Emergency Visit should have been authorized. I did provide my health insurance information to the Emergency Room Admitting Office and they should have initiated the authorization. As such, I should not be penalized for their error.
As this visit was medically necessary, I am requesting the health plan override its denial of this claim. Additionally, I have included a statement of medical necessity from the emergency physician who is also prepared to provide a rebuttal to your decision.
Thank you for your time and consideration.
Statement of medical necessity from the medical provider